DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
ACCIDENT INVESTIGATION REPORT
UNDERGROUND COAL MINE
FATAL MACHINERY ACCIDENT
Mine No. 2 (ID No. 44-06812)
Buchanan Production Company
Grundy, Buchanan County, Virginia
May 12, 2000
Roy D. Davidson, Electrical Engineer
Originating Office - Mine Safety and Health Administration
P.O. Box 560, Wise County Plaza, Norton, Virginia 24273
Ray McKinney, District Manager
On Friday, May 12, 2000, at 7:55 P.M., William M. Blankenship, a 29 year old continuous mining machine operator, received fatal injuries when he was crushed between the continuous mining machine and coal rib. The victim was tramming the machine from outside the operator's deck in the face area of the No. 3 Entry, Left Crosscut on the 001-0 Section using a Moog Model 129 radio remote control unit. Blankenship was positioned between the machine and right rib when he was struck by the cable support bracket that protruded 17.5 inches from the right rear side of the machine. The mining height at this location was 41 inches.
The accident occurred when the victim positioned himself in an unsafe location at a pinch point as he trammed the continuous mining machine from outside the operator's deck with a radio remote control unit. Contributing factors to the accident were: the victim was not given adequate task training on the remote control operation of the continuous mining machine, the remote control unit was designed without an effective emergency stopping device, and the remote control unit was not maintained in a safe operating condition because the mechanical interlocks to prevent accidental movement of the tram controls were rendered ineffective.
Buchanan Production Company's No. 2 Mine is located eight miles northeast of Grundy, Virginia, on Route 701 off State Route 83 in Buchanan County. The mine has been developed approximately 6,000 feet into the Splashdam coal seam which averages 38 to 44 inches locally. The mine opened on April 22, 1996, and operated until February 19, 1999. The mine remained in an idle non-producing status from that date until production resumed on March 22, 2000.
Employment is provided for 25 underground and two surface employees on one production and one maintenance/production shift per day, five days per week. The mine averages 800 tons of raw coal daily from a single seven-entry mechanized mining unit. Coal is transported from the face by a continuous haulage system consisting of four detachable bridges, onto a conveyor belt and then to the outside. Battery-powered personnel carriers and scoop tractors are used to transport both men and material.
The Approved Roof Control Plan includes a procedural section for the remote control operation of the continuous mining machine. Ventilation is provided by one exhausting fan which produces 52,488 cubic feet per minute of air. The latest laboratory analysis of return air samples at the fan showed no methane liberation. The Training Plan was approved on March 9, 2000.
The principal management personnel in charge of the mine at the time of the accident were:
> President ............... Gary A. HornThe mailing address is P.O. Box 16043, Bristol, VA 24209.
Superintendent ............... Bill Sawyers
Safety Director ............... Larry Dickey
Principal Officer - H/S ............... Bill Sawyers
Labor Organization ............... N/A
Chairman - H/S Committee ............... N/A
The last regular Safety and Health inspection was completed on March 31, 2000.
The latest quarterly national accident/injury rate for underground mines was 7.35. The latest quarterly accident/injury rate for this mine is not applicable since the mine began production March 22, 2000 after an idle period.
DESCRIPTION OF THE ACCIDENT
On Friday, May 12, 2000, the Maintenance/Production Crew, under the supervision of Jessie Lester, second shift mine foreman, began work at approximately 4:30 P.M. The crew consisted of Lester and eight other employees. Six of these employees worked on the section, while one worked on the surface and the other on the conveyor belts. Lester and the section crew arrived on the section at approximately 5:00 P.M. and Lester examined all the entries and faces. Lester assigned William Blankenship, who had previously been a roof bolting machine operator, to bolt the left crosscut of the No. 3 Entry and Jimmy Matney, roof bolting machine operator, to bolt the face of No. 4 Entry. Earnest Owens, continuous mining machine helper, and Brian Maggard, No. 4 Bridge operator, began servicing the mining machine. Danny Street, roof bolting machine operator, cleaned coal from the No. 7, 6 and 5 Entries with a scoop tractor. The rest of the crew performed various other duties. At approximately 7:00 P.M., the crew began production in the No. 3 Entry. Lester operated the No. 1 Bridge, which is the closest bridge to the conveyor belt. Having completed production in the No. 3 Entry at approximately 7:25 P.M., Lester assigned Street, a certified mine foreman, to operate the No. 1 Bridge and become designated section foreman during his absence. Lester left the section and traveled toward the surface to conduct a preshift examination on the intake travelway.
The crew began production in the No. 3 Left Crosscut with Stanley Smith, No. 3 Bridge operator in charge of the section crew. After finishing the cut on the left side of the crosscut at 7:55 P.M., Blankenship told the bridge crew to back out of the place. Blankenship had backed the continuous mining machine out of the left side face area and was positioning the machine to finish the right side. Owens was beside Blankenship and then crawled behind the machine to tend the trailing cable. The boom of the continuous mining machine suddenly swung toward Owens and he ducked from its path. Owens turned and saw Blankenship looking at the remote control unit and dropping it as the machine pinned him against the rib. The machine moved for a while longer, continuing to crush the victim, and then stopped.
Owens immediately sought help from Maggard and Smith. Smith instructed Owens to phone outside for a rescue squad as he traveled to the accident scene. Because Blankenship was pinned against the rib, Smith crawled over the machine and into the operator's deck. Smith turned the switch in the operator's deck to the onboard operation from the remote operation and trammed the left side crawler track (cat) forward, which slewed the right rear side of the machine away from the victim. Smith and Maggard moved Blankenship to determine his condition. They detected no breathing. Gary Newberry, beltman, was at the No. 5 belt drive when he was called to bring his personnel carrier to the accident site. When he arrived at the scene, Smith asked him to assist in performing cardio-pulmonary resuscitation (CPR) on Blankenship. They performed CPR and made the decision to transport Blankenship to the outside as quickly as possible. Newberry was told to get the victim's brother, David Blankenship, who had been operating the No. 2 Bridge and take him outside. Street brought the scoop to the accident site and transported the victim and Owens in the bucket toward the surface. Lester, having arrived on the surface after finishing the preshift examination, learned of the accident and called Gary Horn. Lester then traveled back inside with Maggard who had just arrived on the surface. They met the scoop, which moved slower than the personnel carrier used by Lester, near Crosscut 50. The victim was loaded into the personnel carrier and transported to the surface. The Buchanan County Ambulance Service was waiting on the surface and transported Blankenship to Buchanan County General Hospital near Grundy, Virginia. He was pronounced dead at 9:50 P.M. by Dr. Joseph C. Segen.
INVESTIGATION OF THE ACCIDENT
Approximately 8:20 P.M., on May 12, 2000, Stevie Street, Outside Man, contacted Jerry Wiley, Supervisory Coal Mine Health and Safety Inspector, and reported the accident. Jessee Persiani, Supervisory Coal Mine Health and Safety Inspector and Harold Musick, Coal Mine Inspector, arrived at the mine approximately 11:00 P.M. and met with company officials and representatives of the Virginia Division of Mines, Minerals and Energy. Preliminary information concerning the fatality was obtained and a 103-K Order was issued to ensure the safety and health of any persons at the mine. The accident scene was observed and the company officials were told the investigation would continue on May 15, 2000.
An investigation at the mine site began at approximately 10:00 A.M. on May 15, 2000. The investigation was conducted jointly by MSHA and the Virginia Department of Mines, Minerals and Energy. The accident site was inspected and a scaled drawing, photographs and a video were made. The remote control sending unit, receiving unit and battery, used by the victim during the accident, were removed from the site so that further testing could be conducted to help determine the cause of the accident.
Interviews were held on May 17, 2000, at the Virginia Department of Mines, Minerals and Energy's office at Keen Mountain, Virginia. Fourteen persons were interviewed, including all the second shift workers, the superintendent, the day shift section foreman and personnel from the day shift that had operated the continuous mining machine.
The Moog radio remote control unit was tested on May 24, 2000, at the Moog manufacturing facility in East Aurora, New York, and on June 21, 2000 at MSHA's Approval and Certification Center in Triadelphia, West Virginia.
On June 27, 2000, citations related to the accident investigation were issued and a close out conference was conducted.
1. Earnest Owens, the continuous mining machine helper, was an eyewitness to the accident.
2. The mining height at the scene of the accident was 41 inches.
3. The trailing cable support bracket (stand-off) for the continuous mining machine pinned the victim against the rib. This bracket was rigid and protruded 17.5 inches from the right rear side of the machine.
4. The machine involved in the accident was a Simmons-Rand continuous mining machine, Model 525, Serial Number 9708R, Approval Number 2G-3733A-1.
5. The radio remote control unit involved in the accident was a Moog Model 129-231 Permissible Send Unit, Serial No.119M, Approval Number 9B-166-0.
6. The switch located in the operator's deck of the continuous mining machine to govern the operational mode of the machine from either onboard or remote operation was in the remote position at the time of the accident. The switch was changed to onboard operation after the accident so the machine could be moved to free the victim.
7. The remote control unit was found in the operator's deck of the continuous mining machine during the accident investigation. The location of the victim at the cable stand-off behind the operator's deck of the continuous mining machine would have made it unlikely the remote control unit would have fallen in the operator's deck. Stanley Smith stated that he did not remember seeing the remote unit in the operator's deck immediately after the accident when he sat in the deck to move the machine. The remote unit was probably placed in the operator's deck after the machine was moved to free the victim.
8. The Simmons Rand continuous mining machine trams on two independent crawler tracks (cats). Each cat is controlled by a tram control lever on the remote control unit. The right and left tram control levers are self-centering by spring action to a neutral or non-tram position.
9. Each tram lever had a spring applied mechanical interlock that set in a detent when the lever was in the neutral position. This detent prevented movement of the tram levers until the mechanical interlock was lifted from the detent position. This design causes the operator to perform two actions before the machine can be trammed and will help prevent accidental movement of the machine. The mechanical interlocks were taped in the up position thereby rendering this safety feature ineffective.
10. During the accident investigation, the right tram control lever was found in the forward position. The right lever could not self-center because it was bent toward the center of the unit and stuck in this position. The left tram lever was in the neutral position. This arrangement of the levers would cause the right cat to move in a forward motion and the left cat to remain stationary. The continuous mining machine would therefore tend to swerve, as in the accident, with the rear of the machine moving toward the right rib. This situation was re-enacted during the investigation and the machine swerved as stated.
11. The toggle switch which controlled the circuit from the battery to the remote control unit was in the "on" position. This switch must be in the "on" position for the remote control unit to be functional. The switch is located on the side of the unit.
12. With the toggle switch for the battery in the "on" position and the right tram lever stuck in the forward position, the continuous mining machine would have continued to tram and move toward the victim. The eyewitness stated the machine continued to run and crush the victim for a short time after the remote unit was dropped. The machine then stopped.
13. The battery that provides power for the remote control was disconnected from the unit and lying on the mine floor near the cable stand-off at the rear of the continuous mining machine. Disconnecting the battery from the unit de-energizes the machine. Although the battery had been connected to the remote unit at the time of the accident, no one remembered disconnecting the battery from the remote unit after the accident. However, the battery was probably disconnected by someone after the accident. No physical evidence was present at the location where the remote unit and battery were dropped to cause the length of separation necessary to create the tension to disengage the battery cord from the connector on the unit. Also, the cord had to be in direct alignment with the battery connector to be separated from the battery.
14. The remote control has a mercury switch inside the unit that shuts off the continuous mining machine if the unit is turned upside down. The unit was likely turned over as a result of contact with the mining machine or as the unit was dropped to the mine floor. This mercury switch was probably the mechanism by which the machine was stopped at the time of the accident. The mercury switch operated properly when tested.
15. During the investigation, the continuous mining machine was switched to remote control operation and the machine was energized. The machine was trammed using the remote control unit. The machine operated properly with no erratic behavior observed.
16. The Moog radio remote sending and receiving units were tested for proper operation at Moog's facilities by personnel from MSHA's Approval and Certification Center. The units operated properly.
17. Interviews conducted with mine personnel, including personnel who operated the continuous mining machine involved in the accident, indicated they had never observed or heard anyone say the machine ever functioned erratically.
18. The Moog remote control unit was further examined and tested by MSHA's Approval and Certification Center at their headquarters. The tram levers were dismantled and observed to ascertain if the right lever was bent before the accident. No physical characteristics were observed during the examination that indicated the right tram lever had been bent before the accident.
19. Approval and Certification Center personnel conducted additional testing to determine if the victim might have bent the control lever. An identical tram lever was bent to the same position as the lever involved in the accident. Tests revealed that the force necessary to bend the lever to the same position as the lever involved in the accident was between 200 and 300 pounds. This indicated that it was unlikely the victim bent the lever.
20. The victim had six years experience operating a continuous mining machine. The amount of experience the victim had operating a mining machine from the remote position could not be accurately obtained, however he had operated the machine for only four or five cuts while working at this mine.
21. The victim was given task training concerning the onboard operation of the continuous mining machine and the victim was observed operating the machine from the onboard position. The victim was not given task training on the remote operation of the machine nor observed operating the machine from the remote position.
22. The Approved Roof Control Plan has a section for procedures on the remote operation of the continuous mining machine. One provision requires: "At anytime the continuous mining machine is being trammed by remote control, the continuous mining machine operator and all other persons must be outside of the machine's turning radius and away from pinch points created by either the continuous mining machine and/or other equipment."
23. The Moog Model 129 radio remote control unit had no effective emergency stop feature. The unit had a diminutive stop button located on the side of the box behind a wire guard and away from the operational controls. The stop button was not readily accessible in the event of an emergency.
The accident occurred when the victim positioned himself in an unsafe location at a pinch point as he trammed the continuous mining machine outside the operator's deck with a radio remote control unit. Contributing factors to the accident were: the victim was not given adequate task training on the remote control operation of the continuous mining machine, the remote control unit was designed without an effective emergency stopping device, and the remote control unit was not maintained in a safe operating condition because the mechanical interlocks to prevent accidental movement of the tram controls were rendered ineffective.
1. A 103-K Order (No. 7304766) was issued to ensure the safety of all persons in the mine until an investigation was completed and all areas and equipment were deemed safe.
2. A 104(a) Citation (No. 7296990) was issued citing 30CFR 75.220(a). The continuous mining machine operator and helper did not position themselves outside of the machine's turning radius and away from pinch points created by the machine, as the operator trammed the machine using a remote control unit.
3. A 104(d)(1) Citation (No. 7296988) was issued citing 30CFR 75.1725(a). The Moog Model 129-231 radio remote control unit was not maintained in safe operating condition. The tram control lever mechanical interlock safety feature which prevents accidental activation of the tram function was taped in a position to render this device ineffective.
4. A 104(d)(1) Order (No. 7296991) was issued citing 30CFR 48.7(a). William Blankenship was not given adequate task training on his assigned duty as a continuous mining machine operator. Task training was given Blankenship for the onboard operation of the continuous mining machine and he was observed operating the machine from the onboard position. No task training was given Blankenship on the remote control operation of the machine. Blankenship was not observed operating the machine using the remote control unit to determine if he demonstrated safe operating procedures..
Related Fatal Alert Bulletin:
List of persons participating in the investigation:
BUCHANAN PRODUCTION COMPANY - MANAGEMENT
Gary Horn ............... President
Bill Sawyers ............... Superintendent
Larry Dickey ............... Safety Director
Jessie Lester ............... Evening Shift Mine Foreman
Terry Stiltner ............... Day Shift Mine Foreman
BUCHANAN PRODUCTION COMPANY - LABOR
Earnest Owens ............... Continuous Mining Machine Helper
Danny Vance ............... Electrician
> Charles Viers ............... Shop Electrician
VIRGINIA DIVISION OF MINES MINERALS AND ENERGY
Carroll Green ............... Mine Inspection Supervisor
Wayne Davis ............... Coal Mine Technical Specialist
Dwight Miller ............... Coal Mine Technical Specialist
Robert Garrett ............... Coal Mine Technical Specialist
Terry Ratliff ............... Coal Mine Inspector
Jerry Looney ............... Coal Mine Inspector
Joe Altizer ............... Coal Mine Inspector
MSHA APPROVAL AND CERTIFICATION CENTER
Arthur E. Page ............... Electrical Engineer
Michael Snyder ............... Supervisory General Engineer
David S. Creamer ............... Chemist
Wayne Carey ............... Electrical Engineer
MSHA OFFICE OF THE ADMINISTRATOR
Don F. Braenovich ............... Mine Safety and Health Specialist, Safety Division
MINE SAFETY AND HEALTH ADMINISTRATION - DISTRICT 5
Ray McKinney ............... District Manager
James W. Poynter ............... Conference and Litigation Representative
Jesse D. Persiani ............... Supervisory Coal Mine Safety and Health Inspector
Larry Coeburn ............... Supervisory Coal Mine Safety and Health Specialist - Roof Control
Harold G. Musick ............... Coal Mine Safety and Health Inspector
Dennis W. Carter ............... Coal Mine Safety and Health Inspector
Jimmy P. Shelton ............... Coal Mine Safety and Health Inspector
Luther T. Ward ............... Coal Mine Safety and Health Inspector - Electrical
James R. Baker ............... Educational Field Services Specialist
David Woodward ............... Mining Engineer
Russell A. Dresch ............... Electrical Engineer
Roy D. Davidson ............... Electrical Engineer
APPENDIX BListed Below are Those Persons Who Were Interviewed:
Bill Sawyers ............... Superintendent
Jessee Lester ............... Evening Shift Mine Foreman
Terry Stiltner ............... Day Shift Mine Foreman
Earnest Owens ............... Continuous Mining Machine Helper
Stanley Smith ............... No. 3 Bridge Operator
Danny Street ............... No. 1 Bridge Operator
Gary Newberry ............... Beltman
Brian Maggard ............... No. 4 Bridge Operator
Jimmy Matney ............... Roof Bolting Machine Operator
Stevie Street ............... Outside Man
Danny Prater ............... No. 1 Bridge Operator
Billy Carver ............... Continuous Mining Machine Operator
Lonnie Williamson ............... Continuous Mining Machine Helper
Danny Vance ............... Electrician